Urology Coding Alert

Question: One of our patients had an allergic reaction to a drug, causing us to waste nearly the entire vial. How should we code this?


South Dakota Subscriber

Answer: When you have to discard part of a drug, document the amount administered and the amount wasted. Your payer may have specific requirements, like Trailblazer's instruction to append modifier JW (Drug amount discarded/not administered to any patient) to the code for the wasted portion.

The Medicare Claims Processing Manual, Chapter 17, Section 40(www.cms.hhs.gov/manuals/104_claims/clm104c17.pdf) tells you that if you can't avoid discarding a portion of a single-use vial, Medicare will cover the amount of the drug discarded along with the drug administered.

Example: You plan to administer 40 units of a drug, but you must stop administration after three units because of the patient's reaction. You should code the drug and report 40 units.

Another way: Some carriers, like Trailblazer, instead prefer you to report the drug you administered on one line with three units (the amount administered in the example) and on another line report a code for the wasted drug with modifier JW and the remaining 37 units. If you can't divide the units of the drug, code the drug once with the full number of units and append JW to indicate that you discarded a portion.

Note: In the case of termination due to patient reaction, your payer may prefer you to include an additional diagnosis code such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Adverse effect, antineoplastic drug). 

Example: A patient comes to your office to receive a four-month Lupron shot (J9217). During the injection, the patient develops hives, and the urologist discontinues the shot administration. As a result, he doesn't administer the entire four-month dose, and the rest is thrown away.
  
Report diagnoses 185 (Malignant neoplasm of prostate), V64.1 (Surgical or other procedure not carried out because of contraindication), 708.0 (Allergic urticaria) and E933.1. Also, report the services provided using G0356 (Hormonal antineoplastic) and J9217 (Leuprolide acetate [for depot suspension], 7.5 mg) with four units.

For commercial payers that don't accept the new G codes, use 96440 (Chemotherapy administration into pleural cavity, requiring and including thoracentesis) rather than G0356.